Section 1115 SUD Monitoring Report Template (Version 3.0)



1.Title page for the state’s substance use disorder (SUD) demonstration or the SUD component of the broader demonstrationThe state should complete this title page at the beginning of a demonstration and submit as the title page for all monitoring reports. The content of this table should stay consistent over time. Definitions for certain rows are below the table.State Commonwealth of Pennsylvania (Commonwealth or Pennsylvania)Demonstration name Coverage for Former Foster Care Youth from a Different State and Substance Use Disorder (SUD) DemonstrationApproval period for section 1115 demonstrationOctober 1, 2017 through September 30, 2022SUD approved on June 28, 2018SUD demonstration start dateJuly 1, 2018Implementation date of SUD demonstration, if different from SUD demonstration start dateJuly 1, 2018SUD (or if broader demonstration, then SUD -related) demonstration goals and objectivesUnder this demonstration, the Commonwealth expects to achieve the following:Objective 1. Increase rates of identification, initiation, and engagement in treatment.Objective 2. Increase adherence to and retention in treatment.Objective 3. Reduce overdose deaths, particularly those due to opioids.Objective 4. Reduce utilization of Emergency Department (ED) and inpatient hospital settings for treatment where the utilization is preventable or medically inappropriate through improved access to other continuum of care services.Objective 5. Fewer readmissions to the same or higher level of care (LOC) where the readmission is preventable or medically inappropriate.Objective 6. Improve access to care for physical health conditions among beneficiaries.SUD demonstration year and quarterDemonstration Year 2 Quarter 3 (DYQ3)Reporting periodJanuary 1, 2020–March 31, 2020 2.Executive summaryThe executive summary should be reported in the fillable box below. It is intended for summary-level information only. The recommended word count is 500 words or less.MetricsMetric #3 demonstrated an overall upward trend in the number of individuals with SUD diagnoses in DY1. The number of individuals from April to October 2019 was relatively stable. However, the number of members with SUD diagnoses decreased with the onset of the COVID19 pandemic after February 2020.Metrics #6–#12 report the number of members by month receiving services through DYQ3. Prior to February 2020, the unduplicated individuals receiving SUD treatment were generally constant. However, the number of individuals receiving any service decreased with the COVID-19 pandemic after March 2020. This trend is relatively consistent for all of the services received by members under the demonstration up through the end of DYQ3. Metric #7 reports that the number of individuals receiving Early Intervention (EI) is fairly steady over time up until the pandemic.Metric #8 reports the number of individuals receiving Outpatient (OP) services is fairly steady over time up until the pandemic.Metric #9 reports the number of individuals receiving Intensive Outpatient (IOP) and Partial Hospital (PHP) services was fairly steady through April 2019 but has decreased since that time. Note that the Commonwealth’s standards for IOP and PHP have been clarified to better align with the American Society of Addiction Medicine (ASAM) standards and this could account for fewer programs reporting that they provide PHP, which is substantially different under ASAM from the historic Commonwealth service description. Because these services are in congregate settings, almost all utilization dropped off after the beginning of the pandemic in March 2020.Metric #10 reports the number of individuals receiving Residential and Inpatient services is fairly steady over time up until the beginning of the pandemic.Metric #11 reports the number of individuals receiving Withdrawal Management (WM) services is fairly steady over time up until the beginning of the pandemic.Metric #12 reports the number of individuals receiving Medication Assisted Treatment (MAT) services increased. Fifty percent of the increase in 2019 was due to the implementation of Centers of Excellence and initiatives in the Commonwealth to increase MAT usage. MAT for dual eligibles dropped starting January 1, 2020 because of Medicare’s new coverage of MAT with the pandemic affecting utilization starting in February 2020.Metric #23 reports the rate per 1,000 of emergency room visits for SUD continues to decline.The Health Information Technology (HIT) metrics Q1 and Q2 demonstrate that information technology is being used to slow down the rate of growth of individuals identified with SUD by increasing the number of providers registered with and using the Pennsylvania Prescription Drug Monitoring Program (PDMP).The HIT Metrics # S1, S2, and S3 demonstrate that the information technology is being used to effectively treat individuals identified with SUD. The HIT metrics (Q3 and S4) demonstrate that information technology is being used to effectively monitor “recovery supports and services” for individuals identified with SUD. This is occurring through improvements in the overall integration of corrections facilities and EDs with the Health Information Exchange (HIE) and PDMP and the increase in alerts sent.Implementation UpdateAlignment of service definitions with ASAM: The transition to the ASAM from the previous system of care has been proceeding. Throughout 2020, the Commonwealth conducted a systematic “roll out” of service delivery descriptions and expectations beginning with residential services (3.0). The Department of Drug and Alcohol Programs (DDAP) and the Department of Human Services (DHS) communicated changes through in-person discussions, listserv communications, web postings, etc. The Commonwealth has significant buy-in with training and webinars they have been conducting. DHS and DDAP are working together to develop ASAM service descriptions and delivery standards including admission, continuing stay and discharge criteria, the types of services, hours of clinical care, credentials of staff, and implementation of requirements for each LOC. DHS is working to ensure that the coding is consistent with any needed changes.Oversight of provider transition to aligned ASAM service definitions: County program oversight is monitoring the changes to the service definitions and providers are far from alignment at this point. Initially, the Commonwealth faced many political issues that caused significant delays. Pennsylvania has over 900 providers involved in this transition. The Commonwealth has completed an impact analysis to try to anticipate the challenges with alignment of the system of care (services, hours, staff credentials, etc.) with the ASAM LOC criteria. Finally, DHS and DDAP will work to ensure that a cohesive provider monitoring program is in place. Capacity monitoring is anticipated to be embedded in the provider monitoring effort. There are 16 providers who contract under Medicaid who do not have contracts with the Single County Authorities (SCAs). The Office of Mental Health and Substance Abuse Services (OMHSAS) is analyzing its options for ensuring that those Medicaid only providers will comply with ASAM requirements.Contractual changes: The Commonwealth is making the ASAM alignment transition through contractual changes. Staff will evaluate if additional addendums or other contractual requirements are needed. DDAP/DHS expects requirements to be fully aligned with ASAM service delivery in 2021. Provider compliance with the fully aligned ASAM continuum is expected by July 2022. Use of ASAM in assessments and treatment planning: The transition to the use of ASAM in assessments and treatment planning is proceeding well. Pennsylvania has about 8,700 individuals trained in use of ASAM skill training and use of the LOC tool and placement determinations. The Commonwealth has both in-person and online training active as of January 1, 2020. Use of ASAM for patient placement: The transition to using ASAM LOC for a placement tool is also going well given the caveat that the Commonwealth has not fully transitioned to the ASAM service descriptions. DDAP issued guidance to the counties to use The ASAM admission criteria as of May 1, 2018. On March 1, 2019, the ASAM Criteria was required for treatment plans, continued stay, and discharge criteria. Providers are utilizing ASAM Criteria for admission determinations of LOC, but because the service definitions are not yet fully aligned the service delivery is not fully aligned with ASAM. The Commonwealth staff are unable to fully assess how transition to the criteria is affecting access because services do not yet align with the placement criteria. Capacity: With the alignment of provider standards to ASAM, DDAP, and OMHSAS believe there will be sufficient OP and IOP capacity. However, as the alignment occurs it is unclear if there will be sufficient Partial Hospitalization (PH) access given the breadth of changes needed in the industry. ASAM 3.5 should have sufficient access. However, ASAM 3.7 capacity is undetermined because this LOC is also undergoing major changes from the previous definitions. The WM roll out has not started yet so there may be some capacity issues. Transition and Care Coordination: The ASAM alignment will emphasize the required provider standards for transition between LOCs.Budget Neutrality: The Commonwealth continues to report on the 1115 waiver schedules this quarter by Date of Payment. The Commonwealth is using the correct budget neutrality forms for the SUD 1115 quarterly report.3.Narrative information on implementation, by milestone and reporting topicPromptState has no trends/update to report (place an X)Related metric(s) (if any)State response1. Assessment of need and qualification for SUD services1.1 Metric trends1.1.1. The state reports the following metric trends, including all changes (+ or -) greater than 2 percent related to assessment of need and qualification for SUD services Metric #3 Medicaid Beneficiaries with SUD Diagnosis (monthly)Metric #4: Medicaid Beneficiaries with SUD Diagnosis (annually)Metric #5: Medicaid Beneficiaries Treated in an IMD for SUDPlease note: all monthly metrics have been revalidated in 2021, especially those related to MAT. The Commonwealth is refreshing all data from the beginning of the demonstration to present with the re-validated data. The following trends are seen in the data:Analysis DYQ3: Metric #3 reports the number of members by month with a SUD diagnosis through DYQ3. There was an overall upward trend in the number of individuals with SUD diagnoses in DY1. The number of individuals from April to October 2019 was relatively stable. However, the number of members with SUD diagnoses decreased with the onset of the COVID-19 pandemic after February 2020. Despite variation in summer 2019 and with the COVID-19 pandemic after March 2020, there is an upward trend in pregnant women with SUD diagnoses. The number of older adults and children has remained relatively stable. The number of dual eligible individuals with a SUD diagnosis has declined especially with the COVID-19 pandemic.Metrics #4 and #5 are annual metrics and reported for DY1 in the DY2Q1 report for the first time. There is no trend because they were baseline metrics.1.2 Implementation update 1.2.1. Compared to the demonstration design and operational details, the state expects to make the following changes to: The target population(s) of the demonstration X No changes are anticipated.The clinical criteria (e.g., SUD diagnoses) that qualify a beneficiary for the demonstration 1.2.2 The state expects to make other program changes that may affect metrics related to assessment of need and qualification for SUD servicesX The transition to the ASAM from the previous system of care change access to each of the LOCs has been proceeding. Because the Commonwealth is just now rolling out the service descriptions, the providers have used the LOC but have not aligned services to ASAM. It is difficult to know how this is impacting access to LOC. Commonwealth staff are unable to fully assess how transition to the criteria is impacting access because right now services do not align with the criteria.County program oversight is monitoring the changes to the service definitions and providers are far from alignment at this point. Because the Commonwealth has just begun rolling out the alignment expectations — providers are not required to be in compliance with the updated standards until July 2021. The Commonwealth has completed an impact analysis to try to anticipate the challenges with alignment of the system of care (services, hours, staff credentials, etc.) with the ASAM LOC criteria. ASAM 3.7 is a newly updated and defined LOC for Pennsylvania so providers will have challenges. The increased hours across all LOC will provide challenges in terms of staffing.The Commonwealth also anticipates struggles in PH based on what regulatory requirements are and what ASAM is for that LOC. The Commonwealth is assessing where the provider network will land and any response needed.The Commonwealth is making the transition through contractual changes. Staff will evaluate if additional addendums or other contractual requirements are needed.2. Access to Critical Levels of Care for OUD and other SUDs (Milestone 1)2.1 Metric trends2.1.1 The state reports the following metric trends, including all changes (+ or -) greater than 2 percent related to Milestone 1 Metric #6 Any SUD TreatmentMetric #7 Early InterventionMetric #8: Outpatient ServicesMetric #9: Intensive Outpatient and Partial Hospitalization ServicesMetric #10: Residential and Inpatient ServicesMetric #11 – Withdrawal ManagementMetric #12 – Medication Assisted TreatmentMetric #36 Average Length of Stay in IMDsMetrics #6–#12 report the number of members by month receiving services through DYQ3. Prior to February 2020, the unduplicated individuals receiving SUD treatment were generally constant. However, the number of individuals receiving any service decreased with the COVID-19 pandemic after March 2020. This trend is relatively consistent for all of the services received by members under the demonstration up through the end of DYQ3. 1 Metric #6 Unduplicated number is black line; Metrics #7-12 are in the stacked areasBelow, services to pregnant women are seen to be increasing through October 2019 and relatively steady thereafter until the onset of the COVID-19 pandemic in March 2020. 1 Metric #6 Unduplicated number is black line; Metrics #7-12 are in the stacked areasBelow, the number of older adults receiving SUD services remains relatively constant until the beginning of the pandemic.1 Metric #6 Unduplicated number is black line; Metrics #7-12 are in the stacked areasBelow, the number of children receiving SUD services is increasing until the beginning of the pandemic.1 Metric #6 Unduplicated number is black line; Metrics #7-12 are in the stacked areasBelow, the number of dual eligibles receiving services is steady through January 2020. Note: we expected that the MAT for dual eligibles would drop starting January 1, 2020 because of Medicare’s new coverage of MAT. 1 Metric #6 Unduplicated number is black line; Metrics #7-12 are in the stacked areasAnalysis by service: Metric #7 reports the number of individuals receiving EI. The number of individuals receiving EI is fairly steady over time up until the pandemic.Metric #8 reports the number of individuals receiving OP services. The number of individuals receiving OP care is fairly steady over time up until the pandemic.Metric #9 reports the number of individuals receiving IOP and PHP services. The number of individuals receiving IOP and PH was fairly steady through April 2019 but has decreased since that time. Note that the Commonwealth’s standards for IOP and PHP have been clarified to better align with ASAM standards and this could account for fewer programs reporting that they provide PHP, which is substantially different under ASAM from the historic Commonwealth service description. Because these services are in congregate settings, almost all utilization dropped off after the beginning of the pandemic in March 2020.Metric #10 reports the number of individuals receiving Residential and Inpatient services. The number of individuals receiving Residential and Inpatient services is fairly steady over time up until the beginning of the pandemic.Metric #11 reports the number of individuals receiving WM services. The number of individuals receiving WM services is fairly steady over time up until the beginning of the pandemic.Metric #12 reports the number of individuals receiving MAT services. About 50% of the increase in 2019 was due to the implementation of Centers of Excellence and initiatives in the Commonwealth to increase MAT usage. MAT for dual eligibles dropped starting January 1, 2020 because of Medicare’s new coverage of MAT. Metric #36 is an annual metric and reported for DY1 in the DY2Q1 report for the first time. There is no trend because it was a baseline metric.2.2 Implementation update2.2.1 Compared to the demonstration design and operational details, the state expects to make the following changes to: Planned activities to improve access to SUD treatment services across the continuum of care for Medicaid beneficiaries (e.g. outpatient services, intensive outpatient services, medication-assisted treatment, services in intensive residential and inpatient settings, medically supervised withdrawal management)X DY2Q3: The transition to the use of ASAM in assessments and treatment planning is proceeding well. Pennsylvania has about 8,700 individuals trained in use of ASAM skill training and use of the LOC tool and placement determinations. The Commonwealth has both in-person and online training active. The transition to using ASAM LOC for a placement tool is also going well given the caveat that the Commonwealth has not fully transitioned to the ASAM service descriptions.SUD benefit coverage under the Medicaid state plan or the Expenditure Authority, particularly for residential treatment, medically supervised withdrawal management, and medication-assisted treatment services provided to individual IMDs Providers are utilizing ASAM Criteria for admission determinations of LOC, but because the service definitions are not yet aligned, the service delivery is not yet aligned with ASAM. SCAs, who do screening and assessment, are using ASAM for placement criteria but because the service providers are just getting started with the new provider standards, the Commonwealth cannot fully assess the transition. Contractually, new provider standards will not go into effect until July 2021. This year is a warm up to the new standards. 2.2.2 The state expects to make other program changes that may affect metrics related to Milestone 1 SERVICE ALIGNMENT TO ASAM CRITERIA: An ASAM update was released in January 2020 to the provider community.In 2020, DDAP and DHS will be aligning service delivery (hours, service descriptions, staff qualifications) to The ASAM Criteria, 2013. A systematic “roll out” of service delivery descriptions and expectations will occur during the first half of 2020, beginning with residential services (3.0). DDAP and DHS will be communicating details through in-person discussions, listserv communications, web postings, etc. DDAP will continue to align with the ASAM Criteria by no longer delineating two types of 3.5 LOC, i.e., 3.5 Rehabilitative and 3.5 Habilitative. Services including length of stay within a 3.5 LOC should be determined based on the identified needs of the individual within those programs. This change will not result in any loss of capacity or changes in licensing. The focus on providing services that meet the needs of each individual and not the length of stay should support overall quality and continuity of service efforts. Those specialized 3.5 programs, which have been longer in length, and more intense in service, specifically Pregnant Women and Women with Children (PWWWC) services and those programs that have a criminal justice component still have the capacity to offer the services that are necessary, requesting the amount of time needed to address needs identified in the sixdimensional assessment/re-assessment. Client need should always drive length of stay and not be program-driven. DDAP/DHS expects to be fully aligned with service delivery in pliance with the fully aligned ASAM continuum is expected by July 2022.3. Use of Evidence-based, SUD-specific Patient Placement Criteria (Milestone 2)3.1 Metric trends3.1.1 The state reports the following metric trends, including all changes (+ or -) greater than 2 percent related to Milestone 2 XThere are no Centers for Medicare & Medicaid Services (CMS)-provided metrics related to Milestone 2.3.2. Implementation update3.2.1 Compared to the demonstration design and operational details, the state expects to make the following changes to: Planned activities to improve providers’ use of evidence-based, SUD-specific placement criteriaX None.Implementation of a utilization management approach to ensure (a) beneficiaries have access to SUD services at the appropriate level of care, (b) interventions are appropriate for the diagnosis and level of care, or (c) use of independent process for reviewing placement in residential treatment settingsX No changes are anticipated.3.2.2 The state expects to make other program changes that may affect metrics related to Milestone 2X No changes are anticipated.4. Use of Nationally Recognized SUD-specific Program Standards to Set Provider Qualifications for Residential Treatment Facilities (Milestone 3)4.1 Metric trends4.1.1 The state reports the following metric trends, including all changes (+ or -) greater than 2 percent related to Milestone 3Note: There are no CMS-provided metrics related to Milestone 3. If the state did not identify any metrics for reporting this milestone, the state should indicate it has no update to report.X There are no CMS-provided metrics related to Milestone 34.2 Implementation update4.2.1 Compared to the demonstration design and operational details, the state expects to make the following changes to: Implementation of residential treatment provider qualifications that meet the ASAM Criteria or other nationally recognized, SUD-specific program standards OMHSAS and DDAP have had challenges implementing residential provider alignment with ASAM due to the size of the system, trying to coordinate the transition with so many providers trying to do things in the designated timeframes. The Commonwealth has heard concerns about staffing/client ratios, and credentialing; but at this time in the implementation process, these cannot be fully addressed. Providers are expressing concern about the rates and costs because of the extensive involvement of Medicaid managed care and the disparity in rates.Review process for residential treatment providers’ compliance with qualifications. The Commonwealth has received significant buy in from the provider community with training and webinars they have been conducting and moving toward alignment in services with the ASAM Criteria. Today there is a great deal of interest and dialog to align with ASAM and there is buy-in, dialog, and a strong partnership with SCAs. Availability of medication-assisted treatment at residential treatment facilities, either on-site or through facilitated access to services off site The Commonwealth is working through provider compliance with the MAT accessibility requirement, but there remains some degree of stigma regarding MAT and philosophical barriers with providers. The Commonwealth is trying to address this via education, awareness campaigns, etc. MAT accessibility is addressed this in five-year contracts with SCAs as part of the full continuum of care. Geographically there have been concerns about availability in rural areas. The culture shift, while underway, is not completely there yet, but there has been forward movement. OMHSAS and DDAP have constant messaging, working to remove roadblocks by working with the resistant providers and serve as a motivator of change.The Commonwealth has made access to MAT a non-negotiable. This is an evidence based practice and DDAP and OMHSAS have put it in the contracts; created an MAT 101 training that is available online and are in the throes of an anti-stigma campaign putting a face and a voice to people who have used MAT to get there. The Behavioral Health Managed Care Organizations (BHMCOs) have assisted with this campaign as well. 4.2.2 The state expects to make other program changes that may affect metrics related to Milestone 3 DDAP/DHS expects to be fully aligned with service delivery in 2021.5. Sufficient Provider Capacity at Critical Levels of Care including for Medication Assisted Treatment for OUD (Milestone 4)5.1 Metric trends5.1.1 The state reports the following metric trends, including all changes (+ or -) greater than 2 percent related to Milestone 4XMetric #13 SUD Provider AvailabilityMetric #14: SUD Provider Availability - MATMetrics #13 and 14 are annual metrics and reported for DY1 in the DY2Q1 report for the first time. There is no trend because these were a baseline metrics.5.2 Implementation update5.2.1 Compared to the demonstration design and operational details, the state expects to make the following changes to:Planned activities to assess the availability of providers enrolled in Medicaid and accepting new patients in across the continuum of SUD care With the alignment of provider standards to ASAM, DDAP, and OMHSAS believe there will be sufficient OP and IOP capacity. However, as the alignment occurs it is unclear if there will be sufficient PH access given the breadth of changes needed in the industry. ASAM 3.5 should have sufficient access. ASAM 3.7 capacity is undetermined because this LOC is also undergoing major changes from the previous definitions. The WM roll out has not started yet so there may be some capacity issues. This is an area where there may be a fair amount of work to do to build capacity.5.2.2 The state expects to make other program changes that may affect metrics related to Milestone 4 No changes are anticipated.6. Implementation of Comprehensive Treatment and Prevention Strategies to Address Opioid Abuse and OUD (Milestone 5)6.1 Metric trends6.1 The state reports the following metric trends, including all changes (+ or -) greater than 2 percent related to Milestone 5XMetric #15: Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence TreatmentMetric #18 Use of Opioids at High Dosage in Persons Without Cancer Metric #21 Concurrent Use of Opioids and BenzodiazepineMetric #22: Continuity of Pharmacotherapy for Opioid Use Disorder The Commonwealth plans to complete programming of metrics 15, 17, 18, 21, 22, and 25 prior to the DY3Q1 report.6.2 Implementation update6.2.1 Compared to the demonstration design and operational details, the state expects to make the following changes to: Implementation of opioid prescribing guidelines and other interventions related to prevention of OUD On October 28, 2019, Governor Wolf announced that health care providers prescribing controlled substances are required to do so electronically, unless they meet certain exceptions. Act 96 requires the electronic prescribing of controlled substances, which is a deterrent against prescription fraud. Expansion of coverage for and access to naloxone No changes are anticipated.6.2.2 The state expects to make other program changes that may affect metrics related to Milestone 5 No changes are anticipated.7. Improved Care Coordination and Transitions between Levels of Care (Milestone 6)7.1 Metric trends7.1.1 The state reports the following metric trends, including all changes (+ or -) greater than 2 percent related to Milestone 6XMetric #17: Follow-up after Emergency Department Visit for Mental Illness or Alcohol and Other Drug Abuse or DependenceThe Commonwealth plans to complete programming of metrics 15, 17, 18, 21, 22, and 25 prior to the DY3Q1 report.7.2 Implementation update7.2.1 Compared to the demonstration design and operational details, the state expects to make the following changes to: Implementation of policies supporting beneficiaries’ transition from residential and inpatient facilities to community-based services and supports Within the demonstration, the ASAM alignment will emphasize the required provider standards for transition between LOCs. 7.2.2 The state expects to make other program changes that may affect metrics related to Milestone 6 DDAP is planning to provide Care Coordination services separate from the clinical counselors by distinct teams/individuals including ancillary services. DDAP is working on a separate five-year strategic plan for improving Care Coordination services. Any individual with SUD in the Commonwealth regardless of funding who needs Care Coordination will be able to receive it.8. SUD health information technology (health IT)8.1 Metric trends8.1.1 The state reports the following metric trends, including all changes (+ or -) greater than 2 percent related to its health IT metrics Q1. PDMP checking by provider types (prescribers, dispensers).S1. Opioid prescriptions submitted to the PDMPQ2. SSO Connections live.S2. PDMP MME/D threshold exceeded alerts generatedS3. PDMP Multiple Provider Alerts generatedQ3. Corrections Facilities on-boarded to ADTS4. EDs connected to ADTQuestion Area A: The metrics Q1 and Q2 demonstrate that information technology is being used to slow down the rate of growth of individuals identified with SUD by increasing the number of providers registered with and using the PDMP.Q1 (HIT1) PDMP checking by providers (prescribers, dispensers) PDMP Provider Inquiries continue to increase through DYQ3.Q2 (HIT3) Single Sign On Connections live. The number of PDMP connections/users continue to increase through DYQ3. Question Area B: How is information technology being used to treat effectively individuals identified with SUD? Question Area B: The HIT Metrics # S1, #S2, and #S3 demonstrate that the information technology is being used to treat effectively individuals identified with SUD. Actions tracked: Opioid prescriptions dispensed and alerts for high dosage. Note: Alerts began in October 2018.S1 (HIT2): Number of Opioid Prescriptions being dispensed continues to decrease as the number of PDMP queries continue to increase. There were significantly more opioids reported dispensed beginning in January 1, 2019, but the overall trend is still a decrease in dispensed opioids. Since October 2019, the number of opioid prescriptions dispensed have remained under 600,000 with two months falling below 500,000.S2 (HIT4): The number of individuals who receive a dosage of greater than or equal to 90 morphine milligram equivalents (MMEs) per day continues to decrease as measured by number of “Patient Exceeds Opioid Dosage (MME/D) Threshold” alerts generated. The Centers for Disease Control and Prevention (CDC) recommends that prescribers should reassess evidence of the benefits and risks to the individual when increasing dosage to ≥ 50 MME/day (e.g., ≥ 50 mg hydrocodone; ≥ 33 mg oxycodone) and avoid increasing to ≥ 90 MME/day (≥ 90 mg hydrocodone; ≥ 60 mg oxycodone) when possible due to an increased risk of complications. The PDMP has reported fewer than 54,000 alerts since February 2020, dropping below 50,000 twice.S3 (HIT5): The number of patients received controlled substance prescriptions from three or more prescribers, and three or more pharmacists in a three-month period continues to decrease as measured by the PDMP Multiple Provider Alerts generated. The metric has stayed below 27,000 since February 2020, and has even dropped below 20,000 twice.Question Area C: How is information technology being used to effectively monitor “recovery” supports and services for individuals identified with SUD?The HIT metrics (Q3 and S4) demonstrate that information technology is being used to effectively monitor “recovery supports and services” for individuals identified with SUD. This is occurring through improvements in the overall integration of corrections facilities and EDs with the HIE and PDMP and the increase in alerts sent. Q3 (HIT6): The number of corrections connections live has increased over the demonstration. Pennsylvania eHealth is working on establishing connections between all prisons and the gateway, to be able to see information about inmates. This is about using the PDMP through a portal and integration with medical records. Twenty-five corrections facilities have been on-boarded with the HIE. This represents all Commonwealth corrections facilities (there are only 25 Commonwealth correctional facilities) and they are all on-boarded now to the Pennsylvania Patient & Provider Network (P3N), which is the Health Information Exchange in PA. The Commonwealth will now begin working with county facilities to begin on boarding those facilities.S4 (HIT7): Tracking MAT to treat SUDs and prevent opioid overdose using the metric for the number of ED connected to the HIE (HIT PM 7). The cumulative number of alerts sent by EDs (HIT PM 8) continues to increase even though there are fewer hospitals and EDs dispensing Opioids. This is the Hospital Quality Improvement program tracking the number of EDs that are connected to the HIE and sending Automated Admission, Discharge and Transfer (ADT) Alerts. The Commonwealth-wide alerting system tracks the volume of alerting messages over time. Actions Tracked: Individuals connected to alternative therapies from other community-based resources for pain management or general therapy/treatment and number of alerts sent.Note: one hospital with an ED closed in DY2Q2. This resulted in a slight drop in the number of EDs on-boarded with the HIE. Two hospitals began sending inpatient alerts in November 2019. The Health Information Organizations (HIOs) are working to get more hospitals to send inpatient alerts.S4: The cumulative number of alerts sent by emergency rooms and hospitals continues to rise even as the number of alerts sent in any given month have dropped due to reduced emergency room and hospitalization utilization of opioids. It is not possible to distinguish the ED alerts from the hospital inpatient alerts so the number below reflects combined total alerts sent.8.2 Implementation update8.2.1 Compared to the demonstration design and operational details, the state expects to make the following changes to: How health IT is being used to slow down the rate of growth of individuals identified with SUD Question Area A: The metrics Q1 and Q2 demonstrate that information technology is being used to slow down the rate of growth of individuals identified with SUD by increasing the number of providers registered with and using the PDMP.8.2.1.ii.How health IT is being used to treat effectively individuals identified with SUD Question Area B: How is information technology being used to treat effectively individuals identified with SUD? Question Area B: The HIT Metrics # S1, S2, and S3 demonstrate that the information technology is being used to treat effectively individuals identified with SUD. Actions tracked: Opioid prescriptions dispensed and alerts for high dosage. Note: Alerts began in October 2018.How health IT is being used to effectively monitor “recovery” supports and services for individuals identified with SUD Question Area C: The HIT metrics (Q3 and S4) demonstrate that information technology is being used to effectively monitor “recovery supports and services” for individuals identified with SUD. This is occurring through improvements in the overall integration of corrections facilities and EDs with the HIE and PDMP and the increase in alerts sent.Other aspects of the state’s plan to develop the health IT infrastructure/capabilities at the state, delivery system, health plan/MCO, and individual provider levels None.Other aspects of the state’s health IT implementation milestones None.The timeline for achieving health IT implementation milestones None.Planned activities to increase use and functionality of the state’s prescription drug monitoring program None.8.2.2 The state expects to make other program changes that may affect metrics related to health IT None.9. Other SUD-related metrics9.1 Metric trends9.1.1 The state reports the following metric trends, including all changes (+ or -) greater than 2 percent related to other SUD-related metricsXMetric #23: Emergency Department Utilization for SUD per 1,000 Medicaid BeneficiariesMetric #24: Inpatient Stays for SUD per 1,000 Medicaid Beneficiaries Metric #25: Readmissions Among Beneficiaries with SUDMetric #26: Drug Overdose Deaths (count)Metric #27: Drug Overdose Deaths (rate)Metric #32: Access to Preventive/Ambulatory Health Services for Adult Medicaid Beneficiaries with SUD Metrics #24, 26, 27, and 32 are annual metrics and reported for DY1 in the DY2Q1 report for the first time. There is no trend because these were a baseline metrics.The Commonwealth plans to complete programming of metrics 15, 17, 18, 21, 22, and 25 prior to the DY3Q1 report.Metric #23 reports the rate per 1,000 of emergency room visits for SUD. The number of ED visits for SUD per 1,000 beneficiaries continues to decline.ED visits for older adults increased over time while ED visits for children was relatively steady.9.2 Implementation update9.2.1 The state reports the following metric trends, including all changes (+ or -) greater than 2 percent related to other SUD-related metrics 4.Narrative information on other reporting topicsPromptsState has no update to report (Place an X)State response10. Budget neutrality10.1 Current status and analysis10.1.1 If the SUD component is part of a broader demonstration, the state should provide an analysis of the SUD-related budget neutrality and an analysis of budget neutrality as a whole. Describe the current status of budget neutrality and an analysis of the budget neutrality to date. The Commonwealth continues to report on the 1115 waiver schedules this quarter by Date of Payment. The Commonwealth is using the correct BN forms for the SUD 1115 quarterly report.10.2 Implementation update10.2.1 The state expects to make other program changes that may affect budget neutrality The Commonwealth reported on the Commonwealth’s 1115 waiver schedule by Date of Payment only. 11. SUD-related demonstration operations and policy11.1 Considerations11.1.1 The state should highlight significant SUD (or if broader demonstration, then SUD-related) demonstration operations or policy considerations that could positively or negatively affect beneficiary enrollment, access to services, timely provision of services, budget neutrality, or any other provision that has potential for beneficiary impacts. Also, note any activity that may accelerate or create delays or impediments in achieving the SUD demonstration’s approved goals or objectives, if not already reported elsewhere in this document. See report template instructions for more detail. Annual Grievance and Appeal reporting: Complaints (Federally known as Grievances) SFY 2018/2019SFY 2019/2020RateDescriptionN9758799.85%DECREASE in NumeratorD2,9683,5951.21%21% INCREASE in DenominatorGrievances (Federally known as Appeals)SFY 2018/2019SFY 2019/2020RateDescriptionN1173432.93%Almost a threefold INCREASE in SUD Grievances filed D9752,0522.10%A two fold INCREASE in Grievances In looking at SFY 2019/2020 compared to SFY 2018/2019, there was an increase in the SUD complaints filed (numerators) and a decrease in the Mental Health Substance Use Disorder (MH/SUD) complaints filed?(denominators). There was an upward trend in quarterly percentages with one break over eight quarters. BH-MCO reports concerning SUD Complaints (federal language — Grievances)The BH-MCOs have noted an increase in SUD complaint numbers but these were smaller numbers than MH complaints.There were smaller clusters of SUD complaints in OP SUD providers that were newer or had turnover of staff. There has been an ongoing quality improvement effort related to complaints by having consistent collaboration between care management staff and providers.Of the SUD complaints, COVID-19 precautions/protocols Q4 SFY 2019/2020 were a newer complaint area as providers/members tried adjusted to this pandemic (April, May, and June 2020).There have been newer services as related to the opioid epidemic with newer learning processes for Providers.All of the BH-MCOs responding have active review processes to identify opportunities in collaboration when a provider or area has been identified. In analyzing the above Commonwealth SUD grievance (federal language — appeals) numbers in the 1115 waiver, we compared this to the data provided for SFY 2018/2019. We found a sharp decrease in the SUD grievances filed and the MH/SUD denominators in SFY 2019/2020 when compared to SFY 2018/2019. BH-MCO reports concerning SUD Grievances (federal languageappeals)The 1135 waiver of pre-authorization requirements during the COVID-19 pandemic went into effect in May 2020, decreasing denials and thus grievances.There has been a consistent decrease in denials over this time period related to more frequent peer-to-peer consultations. This resulted in decreased grievance numbers. Provider and BH-MCO staff learned to apply ASAM guidelines together as part of the Commonwealth-wide transition initiative. This helped in the interpretation of medical necessity guidelines for SUD treatment thus decreasing denials then grievances.One BH-MCO implemented a system for automated authorization and notification of several SUD LOCs through our provider portal, which lessened the need for prior authorization of SUD services. Another BH-MCO removed the precertification requirements for 2.5 LOC and on April 1, 2020 moved to an alternative payment arrangement because of the COVID-19 pandemic during this period no SUD precertification were required. 11.2 Implementation update11.2.1 Compared to the demonstration design and operational details, the state expects to make the following changes to: How the delivery system operates under the demonstration (e.g. through the managed care system or fee for service) Initially, the Commonwealth faced many political issues that caused significant delays. Pennsylvania has over 900 providers involved in this transition — not like some states with a small number of public funded providers. Pennsylvania has a large number of providers trying to transition; this is not a barrier or a challenge, but this is a large number of providers to transition.Delivery models affecting demonstration participants (e.g. Accountable Care Organizations, Patient Centered Medical Homes) There are 16 providers who contract under Medicaid who do not have contracts with the SCAs. OMHSAS is analyzing its options for ensuring that those Medicaid only providers will comply with ASAM requirements. Partners involved in service delivery The Commonwealth is also working with two sister agencies; forging a major system transformation across the entire Commonwealth. The Drug and Alcohol system is layered; DDAP (managing the system transformation), SCA (responsible for getting the clients the services that they need), OMHSAS (overseeing Medicaid), Primary Contractors and BH-MCOs contracting for Medicaid services, and providers (providing the services)11.2.2 The state experienced challenges in partnering with entities contracted to help implement the demonstration (e.g., health plans, credentialing vendors, private sector providers) and/or noted any performance issues with contracted entities 11.2.3 The state is working on other initiatives related to SUD or OUD The Commonwealth cooperated with the Drug Enforcement Administration’s 19th National Prescription Drug Take-Back Day Initiative on October 24, ernor Wolf launched the nation’s first innovative, evidence-based SUD stigma reduction campaign on September 28, 2020. Life Unites Us is an evidence-based approach to stigma reduction of SUD specifically for Opioid Use Disorder (OUD). The partnership with national nonprofit, Shatterproof, is the first of its kind.The Wolf administration encouraged participation in overdose awareness day on August 31, 2020 to remember those who have lost their battle with ernor Wolf signed the 11th renewal of Opioid Disaster Declaration on August 19, 2020. Governor Wolf released an Opioid command center strategic plan to fight the opioid epidemic on July 6, 2020. Governor Wolf announced more than $2 million in grants for employment services for individuals with OUD on July 2, ernor Wolf awarded $1 million in grants to help veterans overcome SUD on March 2, 2020. Governor Wolf awarded $1.5 million in grants for OUD Criminal Justice Diversion Programs on February 18, ernor Wolf proposed regulations to support MH/SUD coverage regulations on February 3, 2020. Governor Wolf announced $5 million in grants to help individuals in recovery for OUD and their families on January 30, 2020. On December 30, 2019, Governor Wolf announced that the Commonwealth would allocate $5 million in federal funding for loan repayment for health care practitioners providing medical and behavioral health care and treatment for SUD and OUD in areas where there is high opioid-use and a shortage of health care practitioners. On December 3, 2019, Governor Wolf signed the eighth renewal of Pennsylvania’s Opioid Disaster Declaration. In January 2018, he signed the first disaster declaration so the Commonwealth could focus resources and break down government siloes to address the burgeoning heroin and opioid epidemic. On December 2, 2019, Governor Wolf announced that DDAP will award $2.1 million in federal Substance Abuse and Mental Health Services Administration (SAMHSA) grants to enhance community recovery supports for individuals with SUD. On November 7, 2019, Governor Wolf announced that his administration was awarding $3.4 million in federal SAMHSA grants for support services for pregnant and postpartum women with OUD. On October 28, 2019, Governor Wolf announced that health care providers prescribing controlled substances are required to do so electronically, unless they meet certain exceptions. Act 96 requires the electronic prescribing, which is a deterrent against prescription fraud. On October 1, 2019, Governor Wolf kicked of the first Opioid Command Center Opioid Summit: Think Globally, Act Locally. The summit brought 200 individuals helping their communities fight the opioid crisis, including community organizations, non-profits, schools, health care workers, addiction and recovery specialists, and families affected by the opioid crisis.11.2.4 The initiatives described above are related to the SUD or OUD demonstration (The state should note similarities and differences from the SUD demonstration) 12. SUD demonstration evaluation update12.1 Narrative information12.1.1 Provide updates on SUD evaluation work and timeline. The appropriate content will depend on when this report is due to CMS and the timing for the demonstration. There are specific requirements per Code of Federal Regulations (CFR) for annual reports. See report template instructions for more details. CMS approved the Commonwealth’s Evaluation Design on May 22, 2020.The Commonwealth responded to the second round of CMS questions on the Evaluation Design on February 3, 2020.CMS approved the monitoring protocol in December 2020.12.1.2 Provide status updates on deliverables related to the demonstration evaluation and indicate whether the expected timelines are being met and/or if there are any real or anticipated barriers in achieving the goals and timeframes agreed to in the STCs The Commonwealth anticipates submittal of the mid-point assessment in early 2021 consistent with the deadlines agreed upon due to the pandemic. All other deadlines are anticipated to be met.12.1.3 List anticipated evaluation-related deliverables related to this demonstration and their due dates The Commonwealth anticipates submittal of the mid-point assessment in early 2021 consistent with the deadlines agreed upon due to the pandemic. The draft interim evaluation report is due September 30, 2021 and the draft summative evaluation report is due 18 months following the demonstration (March 31, 2024). There are no anticipated barriers to achieving the goals and timeframes related to the demonstration evaluation after the pandemic.13. Other demonstration reporting13.1 General reporting requirements13.1.1 The state reports changes in its implementation of the demonstration that might necessitate a change to approved STCs, implementation plan, or monitoring protocol Any delays or variance with provisions outlined in Standard Terms and Conditions (STCs).DHS and DDAP are working together to develop ASAM service descriptions and delivery standards including admission, continuing stay and discharge criteria, the types of services, hours of clinical care, credentials of staff, and implementation of requirements for each LOC. Admission, continuing stay and discharge criteria are complete. Once the remainder of the ASAM service descriptions and delivery standards are complete, DHS will work to ensure that the coding and rates are consistent with any needed changes. Finally, DHS and DDAP will work to ensure that a cohesive provider monitoring program is in place. Capacity monitoring is anticipated to be embedded in the provider monitoring effort.SERVICE ALIGNMENT TO ASAM CRITERIA: An ASAM update was released in January 2020 to the provider community.In 2020, DDAP and DHS aligned service delivery (hours, service descriptions, staff qualifications) to The ASAM Criteria, 2013. A systematic “roll out” of service delivery descriptions and expectations occurred during the first half of 2020, beginning with residential services (3.0). DDAP and DHS will be communicating details through in-person discussions, listserv communications, web postings, etc. DDAP continued to align with the ASAM Criteria by no longer delineating two types of 3.5 LOC, i.e., 3.5 Rehabilitative and 3.5 Habilitative. Services including length of stay within a 3.5 LOC will be determined based on the identified needs of the individual within those programs. This change will not result in any loss of capacity or changes in licensing. The focus on providing services that meet the needs of each individual and not a predetermined length of stay should support overall quality and continuity of service efforts. Those specialized 3.5 programs, which have been longer in length, and more intense in service, specifically PWWWC services and those programs that have a criminal justice component still have the capacity to offer the services that are necessary, requesting the amount of time needed to address needs identified in the six-dimensional assessment/ re-assessment. Client need should always drive length of stay and not be program-driven.DDAP/DHS expects to be fully aligned with service delivery in July pliance reviews of residential providers are expected to take place in early pliance with the fully aligned ASAM continuum is expected by July 2022.13.1.2 The state anticipates the need to make future changes to the STCs, implementation plan, or monitoring protocol, based on expected or upcoming implementation changes 13.1.3 Compared to the demonstration design and operational details, the state expects to make the following changes to: The schedule for completing and submitting monitoring reports The Commonwealth anticipates submittal of the mid-point assessment in early 2021 consistent with the deadlines agreed upon due to the pandemic. The Commonwealth anticipates submitting DY3Q1 and DY3Q2 reports in March 2021. The content or completeness of submitted reports and/or future reports 13.1.4 The state identified real or anticipated issues submitting timely post-approval demonstration deliverables, including a plan for remediation 13.2 Post-award public forum13.2.2 If applicable within the timing of the demonstration, provide a summary of the annual post-award public forum held pursuant to 42 CFR § 431.420(c) indicating any resulting action items or issues. A summary of the post-award public forum must be included here for the period during which the forum was held and in the annual report. The next post award forum is scheduled for March 2021 due to the pandemic.14. Notable state achievements and/or innovations14.1 Narrative information14.1.1 Provide any relevant summary of achievements and/or innovations in demonstration enrollment, benefits, operations, and policies pursuant to the hypotheses of the SUD (or if broader demonstration, then SUD related) demonstration or that served to provide better care for individuals, better health for populations, and/or reduce per capita cost. Achievements should focus on significant impacts to beneficiary outcomes. Whenever possible, the summary should describe the achievement or innovation in quantifiable terms, e.g., number of impacted beneficiaries. *The state should remove all example text from the table prior to submission.Note: Licensee and states must prominently display the following notice on any display of Measure rates: Measures IET-AD, FUA-AD, FUM-AD, and AAP [Metrics #15, 17(1), 17(2), and 32] are Healthcare Effectiveness Data and Information Set (HEDIS?) measures that are owned and copyrighted by the National Committee for Quality Assurance (NCQA). HEDIS measures and specifications are not clinical guidelines, do not establish a standard of medical care and have not been tested for all potential applications. The measures and specifications are provided “as is” without warranty of any kind. NCQA makes no representations, warranties or endorsements about the quality of any product, test or protocol identified as numerator compliant or otherwise identified as meeting the requirements of a HEDIS measure or specification. NCQA makes no representations, warranties, or endorsement about the quality of any organization or clinician who uses or reports performance measures and NCQA has no liability to anyone who relies on HEDIS measures or specifications or data reflective of performance under such measures and specifications. The measure specification methodology used by CMS is different from NCQA’s methodology. NCQA has not validated the adjusted measure specifications but has granted CMS permission to adjust. A calculated measure result (a “rate”) from a HEDIS measure that has not been certified via NCQA’s Measure Certification Program, and is based on adjusted HEDIS specifications, may not be called a “HEDIS rate” until it is audited and designated reportable by an NCQA-Certified HEDIS Compliance Auditor. Until such time, such measure rates shall be designated or referred to as “Adjusted, Uncertified, Unaudited HEDIS rates.” ................
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